Predictive Value Of Transcranial Doppler To ICP And CPP In Patients Of Intracranial Hypertension

Objective Observe spectra and hemodynamic parameter change of TCD inintracranial hypertension (ICH) (cerebral hemorrhage and intracranial infection)patients to predict ICP & CPP combined with pressure measurement by lumbarpuncture. Observe influence to hemodynamics of middle cerebral artery (MCA),basilar artery (BA) and extracranial segments of internal carotid artery (ICAe)caused by supratentorial ICH, and appraise the value of TCD in ICH. Observespectrum shape change of intracranial and extracranial arteries examined by TCD inpatients before and after ICH treatment and before and after brain death.Methods TCD examination was taken 1 day and 3 days after onset in 45patients with cerebral hemorrhage immediately followed by lumbar punctureexamination. TCD examination was also taken before treatment to ICH in its acutestage and subacute stage or before lumbar puncture treatment. TCD examination andlumbar puncture examination in 42 patients suffered from intracranial infectionwhen needed. 118 patients at the early stage of ICH received 187 times of TCDexamination and lumbar puncture examination in all. Observe spectrum shapechange of intracranial and extracranial arteries examined by TCD in patients beforeand after ICH treatment and before and after brain death. Analyze TCD results andCSF and compare with control group. Record parameter value of TCD about both MCAs, BAs and ICAes, including peak systolic velocity(Vs), end diastolicvelocity(Vd), mean velocity(Vm), and pulsatility index(PI). Lumbar punctureexamination was taken immediately after TCD examination to measure ICP.According to ICP value, patients were divided as: normal ICP group(ICP 5 mmHg～15 mmHg); mild ICH group(15 mmHg～20 mmHg) and moderate ICH group(20mmHg～40 mmHg). Before TCD examination, blood pressure of brachial artery wasmeasured with sphygmomanometer to calculate mean arterial pressure (MAP) andCPP (CPP=MAP-ICP). SPSS10.0 was used as statistic software, data was showed as((?)±s), one-way ANOVA, LSD in multiple comparison,pared-Sampales t test,Independent-Sampales t test and X~2 test are used in group comparison.. Multiplelinear regression was used to analyze parameters of ICP,CPP,TCD and MAP toform regression equation of ICPe and CPPe prediction.Results 1. TCD spectra sharpened to become high resistance waveform withincreasing of ICP, Vd slowed down but Vs had no significant change, and PIincreased. In acute stage of cerebral hemorrhage, waveform of arteries in bleedinghemisphere sharpened, Vm and Vd decreased, and PI increased more significant thannormal hemisphere; there was no significant difference in two sides in patients withintracranial infection. There were reverse blood flow (oscillation wave) in ICAe andCCA before significant increasing of ICH or before brain death in some ICH patients,and the reverse blood flow decreased or disappeared after treatment and such changewas earlier than that of MCA. 2. Correlation coefficient of ICP, PI and Vd inbleeding side was larger than in normal side in patients with cerebral hemorrhage,the more bleeding volume, the slower Vd and the higher PI, there was positivecorrelation between PI value and hematoma volume, correlation coefficient was0.739 and 0.802 in the first and third day after onset. In the first day of onset, therewas no significant hemodynamic change examined by TCD except that Vd decreased and PI increase in massive bleeding group. In the third day of onset, bloodflow rate decreased significantly and PI increased, while there was little influence tohemodynamics of small bleeding. 3. Compared with control group, ICP increased,CPP decreased and blood flow rate increased significantly in patients withintracranial infection; compared with intracranial infection but normal ICP group,CPP and Vd decreased with increasing of ICP, there was little change of Vs and Vm.There was positive correlation between PI and ICP(r=0.594, P＜0.01), there werenegative correlation between PI and CPP(r=-0.259, P＜0.01) and between CPP andICP(r=-0.442, P＜0.01). 4. When ICP was at the same level, hemodynamicparameter such as Vs,Vm and Vd in patients with intracranial infection weresignificantly higher than that in patients with cerebral hemorrhage(P＜0.01); butwhen ICP was moderately increased, PI in patients with cerebral hemorrhage wassignificantly higher than in patients with intracranial infection (P＜0.05). 5.Compared with control group, Vm of ICAe in ICH group decreased, PI of MCA,BAand ICAe all significantly increased; compared with mild ICH group, Vm of MCAand ICAe in moderate ICH group decreased, Vm of BA had no significant change,PI of MCA,BA and ICAe all significantly increased. There was negative correlationbetween ICP and Vm of MCA and ICAe (r=-0.214,-0.073,-0.314,P=0.002,0.160,0.000), correlation between ICP and ICAe was the most significant and therewas no significant correlation between ICP and BA; there was positive correlationbetween ICP and PI(r=0.758,0.428,0.611, all P value was 0.000), correlationbetween ICP and MCA was the most significant. There was significant correlationbetween PI and Vm of MCA and ICAe in ICH patients (r=0.595, 0.718, all P valuewas 0.000). 6. Regression equations of ICP and CPP predicted by hemodynamicparameter of TCD in bleeding side were: ICPe(mmHg)=-7.096+20.474×PI+0.053×MAP(mmHg); CPPe(mmHg)=7.096-20.474×PI+0.947×MAP (mmHg). Predicted differences of ICP and CPP within 5mmHg were 89.9%. correlationcoefficient of ICP and PI was the biggest (r=0.781,P=0.000);and correlationcoefficient of CPP and MAP was the biggest (r=0.940,P=0.000); regressionequations of ICP and CPP predicted by mean hemodynamic parameter of TCD intwo MCAs of patients with intracranial infection were ICPe(mmHg)=1.026+17.165×PI; CPPe(mmHg)=1.411-17.091×PI+0.971×MAP(mmHg). Predicted differencesof ICP and CPP within 5mmHg were 63.28% and 62.5%. Correlation coefficient ofICP and PI was the biggest (r=0.594, P=0.000); and correlation coefficient of CPPand MAP was the biggest(r=0.858, P=0.000).Conclusions 1. TCD spectra become high resistance waveform with sharp systolicpeak, the higher ICP, the sharper waveform in ICH patients. 2. There was positivecorrelation between PI and ICP, there were negative correlation between PI and CPPand between CPP and ICP in ICH patients. PI is the most reliable index to predictICP and has a most significant correlation with ICP. 3. In patients with cerebralhemorrhage,blood flow rate in bleeding side is slower than normal side, and PI ishigher than that in normal side. There is no significant change of hemodynamicparameter in two sides of brain in patients with intracranial infection. There isdifferent hemodynamic change of cerebral blood flow both them. 4. The morebleeding volume, the slower Vd and the higher PI, there was positive correlationbetween PI value and hematoma volume in cerebral hemorrhage patients. PI and Vdare the most reliable index to predict hematoma volume. 5. To evaluate intracranialhypertension the most influencing artery by ICH should be examine. We canappraise ICP by hemodynamic change of ICAe when sound transparent is notsatisfied in both temporal windows. 6.There is cerebral angio spasm in patients withintracranial infection, damage to automatic regulation of cerebral vessels leads toabnormal CPP even in the early stage of ICH. 7. Marked TCD spectra and parameter change can predict ICP and CPP precisely, which can predict cerebral hemorrhagebetter than intracranial infection. 8. Systolic peak flow in MCA and BA, reverseblood flow (oscillation wave) in ICAe and CCA suggests severe ICH or early changebefore brain death, and it is possible recovered after treatment.